Provider Demographics
NPI:1821377334
Name:GECKLER, PHYLLIS YVONNE (LPN)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:YVONNE
Last Name:GECKLER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1381 SAWMILL RD
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-1008
Mailing Address - Country:US
Mailing Address - Phone:580-920-2819
Mailing Address - Fax:
Practice Address - Street 1:5912 HIGHWAY 70 E
Practice Address - Street 2:
Practice Address - City:MEAD
Practice Address - State:OK
Practice Address - Zip Code:73449
Practice Address - Country:US
Practice Address - Phone:580-745-9083
Practice Address - Fax:580-745-9885
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24021164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200049040Medicaid